Enhanced Barrier Precautions-Now Required in Skilled Nursing Facilities
On March 20, 2024, the Centers for Medicare & Medicaid Services (CMS) released QSO-24-08-NH in reference to Enhanced Barrier Precautions in Nursing Homes. The release of this memo was not a surprise to many since it has been anticipated for over a year that CMS would adopt these standards/recommendations made by the Centers for Disease Control and Prevention (CDC).
CMS has issued new guidance for State Survey Agencies and long term care (LTC) facilities on the use of enhanced barrier precautions (EBP) to align with nationally accepted standards. This guidance and the associated requirements are effective April 1, 2024. Those nationally accepted standards are the CDC recommendations released in July 2022, whereby the CDC updated EBP recommendations for “Implementation of PPE Use in nursing homes to prevent spread of MDROs.”
The EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. CMS has stated that the new guidance related to EBP is being incorporated into the nursing home requirements at F880 Infection Prevention and Control.
The guidance to surveyors (and facilities) in F880 now states the following:
“Enhanced Barrier Precautions” (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing.
EBP are indicated for residents with any of the following:
• Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or
• Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.
Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid®) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. A peripheral intravenous line (not a peripherally inserted central catheter) is not considered an indwelling medical device for the purpose of EBP. EBP should be used for any residents who meet the above criteria, wherever they reside in the facility. Facilities have discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by CDC. The CMS QSO memo includes a table to guide facilities and state survey agency staff regarding when Contact Precautions are appropriate and when EBP should be used depending on the resident’s status.
The guidance goes on to state that for residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities such as the following:
• Dressing
• Bathing/showering
• Transferring
• Providing hygiene
• Changing linens
• Changing briefs or assisting with toileting
• Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator
• Wound care: any skin opening requiring a dressing
It is important to note that according to CMS, gowns and gloves would not be recommended when performing or assisting residents with transfers in common areas such as dining or activity rooms, where contact is anticipated to be shorter in duration. However, outside the resident’s room, EBP should be followed when performing transfers or assisting residents during bathing in a shared/common shower room, and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility.
It is important to note that residents are not restricted to their rooms or limited from participation in any group activities. Because EBP do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of a resident’s stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.
Facilities have discretion on how to communicate to staff which residents require the use of EBP. For example, this means a sign does not need to be placed on a resident’s door, however the facility must have a system in place to ensure that staff are aware of which resident’s require EBP, when to use EBP, and have necessary equipment readily available. CMS supports facilities in using creative (e.g., subtle) ways to alert staff when EBP use is necessary to help maintain a
home-like environment, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities.
Facilities should ensure PPE and alcohol-based hand rub are readily accessible to staff. Discretion may be used in the placement of supplies which may include placement near or outside the resident’s room. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident’s room. For example, staff entering the resident’s room to answer a call light, converse with a resident, or provide medications who do not engage in a high-contact resident care activity would not need to employ EBP while interacting with the resident.
The Centers for Disease Prevention and Control (CDC) has a variety of tools and resources to assist facilities with implementing Enhanced Barrier Precautions. Resources from the CDC include a continuing education (CE) webinar recording and slides from November 15, 2022, a pre-implementation planning tool, an observation tool, an observation tool summary spreadsheet, a template letter that can be modified, as well as videos and print resources.
Surveyors have already begun to evaluate the use of EBP when reviewing sampled residents for whom EBP are indicated during full surveys. Their focus will be to evaluate the facilities use of EBP as it relates to CDC-targeted MDROs. CMS will update associated survey documents which will be found under the “Survey Resources” link in the Downloads Section of the CMS Nursing Homes webpage and will also be added to the Long-Term Care Survey Process software application.
If you have questions, please call Elena Madrid at (360) 352-3304, extension 105, or email.